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Liu Y, Zheng L, Li S, Zhang Z, Lin Z, Ma W. Finite element study on the micromechanics of cement-augmented proximal femoral nail anti-rotation (PFNA) for intertrochanteric fracture treatment. Sci Rep 2024; 14:10322. [PMID: 38710745 DOI: 10.1038/s41598-024-61122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/02/2024] [Indexed: 05/08/2024] Open
Abstract
Blade cut-out is a common complication when using proximal femoral nail anti-rotation (PFNA) for the treatment of intertrochanteric fractures. Although cement augmentation has been introduced to overcome the cut-out effect, the micromechanics of this approach remain to be clarified. While previous studies have developed finite element (FE) models based on lab-prepared or cadaveric samples to study the cement-trabeculae interface, their demanding nature and inherent disadvantages limit their application. The aim of this study was to develop a novel 'one-step forming' method for creating a cement-trabeculae interface FE model to investigate its micromechanics in relation to PFNA with cement augmentation. A human femoral head was scanned using micro-computed tomography, and four volume of interest (VOI) trabeculae were segmented. The VOI trabeculae were enclosed within a box to represent the encapsulated region of bone cement using ANSYS software. Tetrahedral meshing was performed with Hypermesh software based on Boolean operation. Finally, four cement-trabeculae interface FE models comprising four interdigitated depths and five FE models comprising different volume fraction were established after element removal. The effects of friction contact, frictionless contact, and bond contact properties between the bone and cement were identified. The maximum micromotion and stress in the interdigitated and loading bones were quantified and compared between the pre- and post-augmentation situations. The differences in micromotion and stress with the three contact methods were minimal. Micromotion and stress decreased as the interdigitation depth increased. Stress in the proximal interdigitated bone showed a correlation with the bone volume fraction (R2 = 0.70); both micromotion (R2 = 0.61) and stress (R2 = 0.93) at the most proximal loading region exhibited a similar correlation tendency. When comparing the post- and pre-augmentation situations, micromotion reduction in the interdigitated bone was more effective than stress reduction, particularly near the cement border. The cementation resulted in a significant reduction in micromotion within the loading bone, while the decrease in stress was minimal. Noticeable gradients of displacement and stress reduction can be observed in models with lower bone volume fraction (BV/TV). In summary, cement augmentation is more effective at reducing micromotion rather than stress. Furthermore, the reinforcing impact of bone cement is particularly prominent in cases with a low BV/TV. The utilization of bone cement may contribute to the stabilization of trabecular bone and PFNA primarily by constraining micromotion and partially shielding stress.
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Affiliation(s)
- Yurui Liu
- Department of Anesthesiology, Beijing Stomatological Hospital, School of Stomatology, Capital Medical University, Beijing, China
| | - Liqin Zheng
- Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shaobin Li
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhengze Zhang
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziling Lin
- Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wuhua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
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Joeris A, Kabiri M, Galvain T, Vanderkarr M, Holy CE, Plaza JQ, Schneller J, Kammerlander C. Nail fixation of unstable trochanteric fractures with or without cement augmentation: A cost-utility analysis in the United States: Cost-utility of cement augmentation. Injury 2024; 55:111445. [PMID: 38428102 DOI: 10.1016/j.injury.2024.111445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/19/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVES Recent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective. METHODS The cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients' lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results. RESULTS Fixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of -$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively. CONCLUSION Fixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement.
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Affiliation(s)
- Alexander Joeris
- AO Innovation Translation Center Clinical Science, AO Foundation, Davos, Switzerland
| | - Mina Kabiri
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA
| | - Thibaut Galvain
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA
| | | | - Chantal E Holy
- Medical Device Epidemiology, Johnson & Johnson, New Brunswick, NJ, USA
| | | | - Julia Schneller
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Christian Kammerlander
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany; AUVA Trauma Hospital Styria, Graz, Austria; AUVA Trauma Hospital Styria, Kalwang, Austria.
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Fernandez M, Du Bourg VM, David Y, Dubrana F, Letissier H, Di Francia R. Augmented versus non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails for treating trochanteric fractures in patients over sixty-five years of age. INTERNATIONAL ORTHOPAEDICS 2024; 48:831-840. [PMID: 38159137 DOI: 10.1007/s00264-023-06073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Intramedullary nailing is a common treatment for pertrochanteric fractures. However, implant-related mechanical failures, such as cut-out and cut-through, lead to higher rates of revision surgery, loss of autonomy, and mortality. Cemented augmentation enhances the bone-implant interface. This study compared the frequency of mechanical failures between augmented and non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails. METHODS This descriptive, retrospective study at a level 1 trauma centre included patients aged > 65 years with pertrochanteric fractures treated by a short augmented or non-augmented TFNA nail. The primary outcome was the comparison of cut-out or cut-through rates between groups at three and six months postoperatively. RESULTS Of the 181 patients analysed, 103 had augmented TFNA nails and 78 had non-augmented TFNA nails. There were no statistically significant differences between groups in terms of demographic characteristics, AO/OTA classification, or quality of reduction. The failure rate was significantly lower in the augmented group than in the non-augmented group: 1 (0.97%) versus 9 (11.54%) (p = 0.005). At six months postoperatively, there was no significant difference between the two groups concerning functional recovery, as measured by the Parker and EuroQoL 5-Dimensions scores. CONCLUSIONS For patients aged over 65 years, the use of the augmented TFNA nail may reduce the risk of fixation failures such as cut-out.
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Affiliation(s)
- Marie Fernandez
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Valentin Merle Du Bourg
- Service d'Orthopédie Et de Traumatologie, CHU Grenoble Alpes - Hôpital Sud, Avenue de Kimberley, 38130, Echirolles, France
| | - Yoann David
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Frédéric Dubrana
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Hoel Letissier
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Rémi Di Francia
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France.
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Mayor J, Birgel V, Clausen JD, Aktas G, Sehmisch S, Einfeldt AK, Giannoudis V, Abdelaal AHK, Liodakis E. Lessons learned from biomechanical studies on cephalomedullary nails for the management of intertrochanteric fractures. A scoping review. Injury 2024; 55:111180. [PMID: 37972488 DOI: 10.1016/j.injury.2023.111180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The increasing socioeconomic need for optimal treatment of hip fractures in combination with the high diversity of available implants has raised numerous biomechanical questions. This study aims to provide a comprehensive overview of biomechanical research on the treatment of intertrochanteric fractures using cephalomedullary devices. METHODS Following the PRISMA-P guidelines, a systematic literature search was performed on 31.12.2022. The databases PubMed/MEDLINE and Web of Science were searched. Scientific papers published between 01.01.2000 - 31.12.2022 were included when they reported data on implant properties related to the biomechanical stability for intertrochanteric fractures. Data extraction was undertaken using a synthesis approach, gathering data on criteria of implants, sample size, fracture type, bone material, and study results. RESULTS The initial search identified a total of 1459 research papers, out of which forty-three papers were considered for final analysis. Due to the heterogeneous methods and parameters used in the included studies, meta-analysis was not feasible. A comprehensive assessment of implant characteristics and outcome parameters was conducted through biomechanical analysis. Various factors such as proximal and distal locking, nail diameter and length, fracture model, and bone material were thoroughly evaluated. CONCLUSION This scoping review highlights the need for standardization in biomechanical studies on intertrochanteric fractures to ensure reliable and comparable results. Strategies such as avoiding varus, maintaining a sufficient tip-apex-distance, cement augmentation, and optimizing lesser trochanteric osteosynthesis enhance construct stability. Synthetic alternatives may offer advantages over cadaveric bone. Further research and meta-analyses are required to establish standardized protocols and enhance reliability.
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Affiliation(s)
- Jorge Mayor
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany.
| | - Vera Birgel
- Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover, Germany
| | - Jan-Dierk Clausen
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Gökmen Aktas
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Stephan Sehmisch
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Ann-Kathrin Einfeldt
- Laboratory for Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Str. 1-7, Hannover 30625, Germany
| | - Vasilis Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom
| | - Ahmed H K Abdelaal
- Department of Orthopedic Surgery, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
| | - Emmanouil Liodakis
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
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Hoelscher-Doht S, Heilig M, von Hertzberg-Boelch SP, Jordan MC, Gbureck U, Meffert RH, Heilig P. Experimental magnesium phosphate cement paste increases torque of trochanteric fixation nail advanced™ blades in human femoral heads. Clin Biomech (Bristol, Avon) 2023; 109:106088. [PMID: 37660575 DOI: 10.1016/j.clinbiomech.2023.106088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The use of polymethylmethacrylate cement for in-situ implant augmentation has considerable disadvantages: it is potentially cytotoxic, exothermic and non-degradable. Therefore, the primary aim of this study was to develop a magnesium phosphate cement which meets the requirements for in-situ implant augmentation as an alternative. Secondly, this experimental cement was compared to commercial bone cements in a biomechanical test set-up using augmented femoral head blades. METHODS A total of 40 human femoral heads were obtained from patients who underwent total hip arthroplasty. After bone mineral density was quantified, specimens were assigned to four treatment groups. A blade of the Trochanteric Fixation Nail Advanced™ was inserted into each specimen and augmented with either Traumacem™ V+, Paste-CPC, the experimental magnesium phosphate cement or no cement. A rotational load-to-failure-test (0° to 90°) was performed. FINDINGS A conventional two-component magnesium phosphate cement failed in-situ implant augmentation consistently due to filter pressing. Only a glycerol-based magnesium phosphate paste was suitable for the augmentation of femoral head blades. While the blades augmented with Traumacem™ V+ yielded the highest maximum torque overall (22.1 Nm), the blades augmented with Paste-CPC and the magnesium phosphate paste also showed higher maximum torque values (15.8 and 12.8 Nm) than the control group (10.8 Nm). INTERPRETATION This study shows for the first time the development of a degradable magnesium phosphate cement paste which fulfills the requirements for in-situ implant augmentation. Simultaneously, a 48% increase in stability is demonstrated for a scenario where implant anchorage is difficult in osteoporotic bone.
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Affiliation(s)
- Stefanie Hoelscher-Doht
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | - Maximilian Heilig
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | | | - Martin Cornelius Jordan
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | - Uwe Gbureck
- Department for Functional Materials in Medicine and Dentistry, University of Wuerzburg, Pleicherwall 2, 97070, Wuerzburg, Germany
| | - Rainer Heribert Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | - Philipp Heilig
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany.
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Piccirilli E, Cariati I, Primavera M, Triolo R, Gasbarra E, Tarantino U. Augmentation in fragility fractures, bone of contention: a systematic review. BMC Musculoskelet Disord 2022; 23:1046. [PMID: 36457070 PMCID: PMC9717408 DOI: 10.1186/s12891-022-06022-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Osteoporosis is a complex multifactorial disease characterized by reduced bone mass and microarchitectural deterioration of bone tissue linked to an increase of fracture risk. Fragility fractures occur in osteoporotic subjects due to low-energy trauma. Osteoporotic patients are a challenge regarding the correct surgical planning, as it can include fixation augmentation techniques to reach a more stable anchorage of the implant, possibly lowering re-intervention rate and in-hospital stay. METHODS The PubMed database and the Google Scholar search engine were used to identify articles on all augmentation techniques and their association with fragility fractures until January 2022. In total, we selected 40 articles that included studies focusing on humerus, hip, spine, and tibia. RESULTS Literature review showed a quantity of materials that can be used for reconstruction of bone defects in fragility fractures in different anatomic locations, with good results over the stability and strength of the implant anchorage, when compared to non-augmented fractures. CONCLUSION Nowadays there are no recommendations and no consensus about the use of augmentation techniques in osteoporotic fractures. Our literature review points at implementing the use of bone augmentation techniques with a specific indication for elderly patients with comminuted fractures and poor bone quality.
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Affiliation(s)
- Eleonora Piccirilli
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - Ida Cariati
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy.
| | - Matteo Primavera
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
| | - Rebecca Triolo
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
| | - Elena Gasbarra
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
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Pastor T, Zderic I, Gehweiler D, Gardner MJ, Stoffel K, Richards G, Knobe M, Gueorguiev B. Biomechanical analysis of recently released cephalomedullary nails for trochanteric femoral fracture fixation in a human cadaveric model. Arch Orthop Trauma Surg 2022; 142:3787-3796. [PMID: 34748055 DOI: 10.1007/s00402-021-04239-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recently, two novel concepts for intramedullary nailing of trochanteric fractures using a helical blade or interlocking dual screws have demonstrated advantages as compared to standard single-screw systems. However, these two concepts have not been subjected to a direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone quality (1) the biomechanical competence of nailing with the use of a helical blade versus interlocking screws, and (2) the effect of cement augmentation on the fixation strength of the helical blade. METHODS Twelve osteoporotic and osteopenic human cadaveric femoral pairs were assigned for pairwise implantation using either a short TFN-ADVANCED Proximal Femoral Nailing System (TFNA) with a helical blade head element or a short TRIGEN INTERTAN Intertrochanteric Antegrade Nail (InterTAN) with interlocking screws. Six osteoporotic femora, implanted with TFNA, were augmented with bone cement. Four groups were created: group 1 (TFNA) paired with group 2 (InterTAN), both consisting of osteopenic specimens, and group 3 (TFNA augmented) paired with group 4 (InterTAN), both consisting of osteoporotic specimens. An unstable trochanteric AO/OTA 31-A2.2 fracture was simulated and all specimens were tested until failure under progressively increasing cyclic loading. RESULTS Stiffness in group 3 was significantly higher versus group 4, p = 0.03. Varus (°) and femoral head rotation around the femoral neck axis (°) after 10,000 cycles were 1.9 ± 1.0/0.3 ± 0.2 in group 1, 2.2 ± 0.7/0.7 ± 0.4 in group 2, 1.5 ± 1.3/0.3 ± 0.2 in group 3 and 3.5 ± 2.8/0.9 ± 0.6 in group 4, being significantly different between groups 3 and 4, p = 0.04. Cycles to failure and failure load (N) at 5° varus or 10° femoral head rotation around the neck axis in groups 1-4 were 21,428 ± 6020/1571.4 ± 301.0, 20,611 ± 7453/1530.6 ± 372.7, 21,739 ± 4248/1587.0 ± 212.4 and 18,622 ± 6733/1431.1 ± 336.7, being significantly different between groups 3 and 4, p = 0.04. CONCLUSIONS Nailing of trochanteric femoral fractures with use of helical blades is comparable to interlocking dual screws fixation in femoral head fragments with low bone quality. Bone cement augmentation of helical blades provides significantly greater fixation strength compared to interlocking screws constructs.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, Davos, Switzerland.
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA
| | | | | | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Comparison of Helical Blade Systems for Osteoporotic Intertrochanteric Fractures Using Biomechanical Analysis and Clinical Assessments. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121699. [PMID: 36556901 PMCID: PMC9783162 DOI: 10.3390/medicina58121699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Abstract
Background and Objectives: This study aimed to compare the biomechanical properties and outcomes of osteoporotic intertrochanteric fractures treated with two different helical blade systems, the trochanteric fixation nail-advanced (TFNA) and proximal femoral nail antirotation II (PFNA), to evaluate the efficacy and safety of the newly introduced TFNA system. Materials and Methods: A biomechanical comparison of the two helical blades was performed using uniaxial compression tests on polyurethane foam blocks of different densities. The peak resistance (PR) and accumulated resistance (AR) were measured during the 20 mm advancement through the test block. For clinical comparison, 63 osteoporotic intertrochanteric fractures treated with TFNA were identified and compared with the same number of fractures treated with PFNA using propensity score matching. Ambulatory status, medial migration, lateral sliding, fixation failure, and patient-reported outcomes were compared between the two groups over a minimum of 1 year's follow up. Results: The uniaxial compression test showed that a slightly, but significantly lower resistance was required to advance the TFNA through the test block compared with the PFNA (20 PCF, p = 0.017 and p = 0.026; 30 PCF, p = 0.007 and p = 0.001 for PR and AR, respectively). Clinically, the two groups showed no significant differences in post-operative ambulatory status and patient-reported outcomes. However, in TFNA groups, significantly more medial migration (TFNA, 0.75 mm; PFNA, 0.40 mm; p = 0.0028) and also, lateral sliding was noted (TFNA, 3.99 mm; PFNA, 1.80 mm; p = 0.004). Surgical failure occurred in four and two fractures treated with the TFNA and PFNA, respectively. Conclusions: The results of our study suggest that the newly introduced TFNA provides clinical outcomes comparable with those of the PFNA. However, inferior resistance to medial migration in the TFNA raises concerns regarding potential fixation failures.
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Joeris A, Kabiri M, Galvain T, Vanderkarr M, Holy CE, Plaza JQ, Tien S, Schneller J, Kammerlander C. Cost-Effectiveness of Cement Augmentation Versus No Augmentation for the Fixation of Unstable Trochanteric Fractures. J Bone Joint Surg Am 2022; 104:2026-2034. [PMID: 36053020 DOI: 10.2106/jbjs.21.01516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer's perspective. METHODS The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient's lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses. RESULTS The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%. CONCLUSIONS Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available. LEVEL OF EVIDENCE Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander Joeris
- AO Innovation Translation Center, Clinical Science, AO Foundation, Davos, Switzerland
| | - Mina Kabiri
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, New Jersey
| | - Thibaut Galvain
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, New Jersey
| | | | - Chantal E Holy
- Medical Device Epidemiology, Johnson & Johnson, New Brunswick, New Jersey
| | | | - Stephanie Tien
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, New Jersey
| | - Julia Schneller
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Christian Kammerlander
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany.,AUVA Trauma Hospital Styria, Graz, Austria.,AUVA Trauma Hospital Styria, Kalwang, Austria
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10
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Pastor T, Zderic I, Schopper C, Haefeli PC, Kastner P, Souleiman F, Gueorguiev B, Knobe M. Impact of Anterior Malposition and Bone Cement Augmentation on the Fixation Strength of Cephalic Intramedullary Nail Head Elements. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1636. [PMID: 36422175 PMCID: PMC9696484 DOI: 10.3390/medicina58111636] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Intramedullary nailing of trochanteric fractures can be challenging and sometimes the clinical situation does not allow perfect implant positioning. The aim of this study was (1) to compare in human cadaveric femoral heads the biomechanical competence of two recently launched cephalic implants inserted in either an ideal (centre-centre) or less-ideal anterior off-centre position, and (2) to investigate the effect of bone cement augmentation on their fixation strength in the less-ideal position. Materials and Methods: Fourty-two paired human cadaveric femoral heads were assigned for pairwise implantation using either a TFNA helical blade or a TFNA screw as head element, implanted in either centre-centre or 7 mm anterior off-centre position. Next, seven paired specimens implanted in the off-centre position were augmented with bone cement. As a result, six study groups were created as follows: group 1 with a centre-centre positioned helical blade, paired with group 2 featuring a centre-centre screw, group 3 with an off-centre positioned helical blade, paired with group 4 featuring an off-centre screw, and group 5 with an off-centre positioned augmented helical blade, paired with group 6 featuring an off-centre augmented screw. All specimens were tested until failure under progressively increasing cyclic loading. Results: Stiffness was not significantly different among the study groups (p = 0.388). Varus deformation was significantly higher in group 4 versus group 6 (p = 0.026). Femoral head rotation was significantly higher in group 4 versus group 3 (p = 0.034), significantly lower in group 2 versus group 4 (p = 0.005), and significantly higher in group 4 versus group 6 (p = 0.007). Cycles to clinically relevant failure were 14,919 ± 4763 in group 1, 10,824 ± 5396 in group 2, 10,900 ± 3285 in group 3, 1382 ± 2701 in group 4, 25,811 ± 19,107 in group 5 and 17,817 ± 11,924 in group 6. Significantly higher number of cycles to failure were indicated for group 1 versus group 2 (p = 0.021), group 3 versus group 4 (p = 0.007), and in group 6 versus group 4 (p = 0.010). Conclusions: From a biomechanical perspective, proper centre-centre implant positioning in the femoral head is of utmost importance. In cases when this is not achievable in a clinical setting, a helical blade is more forgiving in the less ideal (anterior) malposition when compared to a screw, the latter revealing unacceptable low resistance to femoral head rotation and early failure. Cement augmentation of both off-centre implanted helical blade and screw head elements increases their resistance against failure; however, this effect might be redundant for helical blades and is highly unpredictable for screws.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland
| | - Clemens Schopper
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Pascal C Haefeli
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Philipp Kastner
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Firas Souleiman
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | | | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
- Medical Faculty, University of Zurich, 8091 Zurich, Switzerland
- Medical Faculty, RWTH Aachen University Hospital, 52074 Aachen, Germany
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11
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Huyke-Hernández FA, Only AJ, Sorich M, Onizuka N, Switzer JA, Cunningham BP. Outcomes After Revision Fixation With Cement Augmentation for Failed Intertrochanteric Fracture Fixation in Older Adult Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221135480. [PMID: 36310893 PMCID: PMC9608033 DOI: 10.1177/21514593221135480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure. Methods This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality. Results Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved. Conclusions Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.
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Affiliation(s)
- Fernando A. Huyke-Hernández
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
| | - Arthur J. Only
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
| | - Megan Sorich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Naoko Onizuka
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Julie A. Switzer
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Brian P. Cunningham
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA,Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA,Brian P. Cunningham MD, Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, 6500 Excelsior Boulevard, St Louis Park, MN 55426, USA.
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12
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Bi W, Xu J, Dong Z, Wang Z, Li J, Shang Y, Wu J. Clinical Analysis of Surgical Treatment of Senile Intertrochanteric Fracture Based on Intelligent Knowledge of Health Care. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3556330. [PMID: 35854781 PMCID: PMC9279043 DOI: 10.1155/2022/3556330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
In order to explore the clinical application value of intelligent health care knowledge combined with closed reduction intramedullary nail fixation in elderly patients with intertrochanteric fracture of the femur, a retrospective analysis is performed on 80 elderly patients who received intertrochanteric surgery from January 2019 to January 2021. All patients were divided into study group and control group based on intelligent medical knowledge received or not. During the phase of treatment, both the two groups were treated with closed reduction and intramedullary nailing. The control group received conventional knowledge training and rehabilitation before and after the surgery, and the research group received additional intelligent medical knowledge health care. Observations of patients after bed and ground time are compared and the VAS score is used to evaluate the pain degree at 12 h, 24 h, and 48 h after surgery. Besides, the incidence of postoperative complications in the two groups is observed. From the clinical follow-up results, it is clearly evident that intramedullary nail fixation based on medical care knowledge can effectively improve the hip function and quality of life in patients, reduce postoperative pain, and improve the prognosis of elderly patients with femoral trochanteric fracture.
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Affiliation(s)
- Weidong Bi
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Jianjie Xu
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Zhihui Dong
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Zhaona Wang
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Jiebing Li
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Yongwei Shang
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Jianzhong Wu
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
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13
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Liu S, Wu D, Zhao J, Yang T, Sun J, Gong K. Novel crescent drill design and mechanistic force modeling for thrust force reduction in bone drilling. Med Eng Phys 2022; 103:103795. [PMID: 35500995 DOI: 10.1016/j.medengphy.2022.103795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
Bone drilling tends to cause mechanical damages and thermal necrosis in the vicinity of the drilled hole, which can deteriorate the surgery quality and patients' recovery. Understanding the cutting forces generation mechanism is crucial in controlling thrust force and bone temperature for optimum tool design. In this study, a novel crescent drill bit featuring an improved positive rake angle distribution was designed to reduce the thrust force and temperature elevation. On this basis, a mechanistic model for predicting thrust force and torque was proposed for drill bits with different geometries (twist drill and crescent drill). The proposed model was established in the polar coordinate system to precisely calculate the curvilinear integral of the crescent cutting edges. Drilling experiments were carried out using two types of drill bit under different cutting conditions and results showed that our proposed model agrees well with the experimental data. The experimental results also demonstrated that our tool design can significantly reduce the thrust force and reduce the bone temperature below the thermal threshold without coolant, providing a clinical option for coolant free drilling.
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Affiliation(s)
- Sinan Liu
- School of Control and Mechanical Engineering, Tianjin Chengjian University, Tianjin 300384, China
| | - Di Wu
- School of Control and Mechanical Engineering, Tianjin Chengjian University, Tianjin 300384, China
| | - Jian Zhao
- School of Control and Mechanical Engineering, Tianjin Chengjian University, Tianjin 300384, China.
| | - Tao Yang
- School of Mechanical Engineering, Tiangong University, Tianjin 300387, China
| | - Jie Sun
- Tianjin Hospital, Tianjin 300211, China
| | - Kun Gong
- School of Control and Mechanical Engineering, Tianjin Chengjian University, Tianjin 300384, China
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14
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van Veelen NM, Beeres FJ, Link BC, Babst R. [Augmentation in the treatment of proximal humeral and femoral fractures]. Unfallchirurg 2022; 125:436-442. [PMID: 35416480 DOI: 10.1007/s00113-022-01172-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Proximal humeral and trochanteric femoral fractures in older patients are typically caused by low-energy trauma and are therefore often associated with osteoporosis. The treatment of such fragility fractures can be difficult as implant purchase is reduced in osteoporotic bone. By augmenting the fixation with cement the contact surface between implant and bone can be increased, which improves the stability of the osteosynthesis. OBJECTIVE This article describes the operative technique for the augmentation of trochanteric femoral fractures treated with the Trochanteric Fixation Nail-Advanced (TFNA, DePuy Synthes, Oberdorf BL, Switzerland) and proximal humeral fractures stabilized with a PHILOS plate (DePuy Synthes). Furthermore, the evidence for the augmentation of these two fracture types is elucidated. RESULTS Biomechanical studies could show an improved stability of the osteosynthesis after successful augmentation for both fracture types. The current evidence also indicates a clinical reduction of fixation failure. Whether the augmentation has an influence on the functional result could so far not yet clearly be proven. CONCLUSION Augmentation seems to be a safe and valuable addition to available treatment options especially for patients with fragility fractures.
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Affiliation(s)
- Nicole M van Veelen
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz
| | - Frank Jp Beeres
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz
| | - Björn-Christian Link
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz
| | - Reto Babst
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz. .,Departement Gesundheitswissenschaften und Medizin, Universität Luzern, Frohburgstraße 3, 6002, Luzern, Schweiz.
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15
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Cho HM, Park KM, Jung TG, Park JY, Lee Y. Conventional versus helical blade screw insertion following the removal of the femoral head screw: a biomechanical evaluation using trochanteric gamma 3 locking nail versus PFN antirotation. BMC Musculoskelet Disord 2021; 22:767. [PMID: 34496801 PMCID: PMC8428115 DOI: 10.1186/s12891-021-04658-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE When a hip screw needs to be changed, choosing between the conventional (C-type) and helical blade (H-type) types is difficult. In this biomechanical study, we compared these two screw types relative to the type of the initial screw used. METHODS C- or H-type screws were inserted (leading screw) in three types of polyurethane bone models (Sawbone, Pacific Research Laboratories, Inc., Washington, USA: 130 × 180 × 40 mm) of different bone mineral densities (pounds per cubic feet [PCF] 5, 80 kg/m3; PCF 10, 160 kg/m3; and PCF 15, 240 kg/m3), and then successively or alternately inserted (following screw) after the leading screw removal. An original model (original C and H) of a leading screw without removal was created as a control. The strengths of resistance to pullout (PO) and rotational stress were measured. For each experimental condition, there were 30 experimental models. RESULTS The original C screw was superior in PO strength, and the original H-type screw was superior in rotational strength. When the C- or H-type screw was the leading screw, using the C-type screw again as the following screw (C1-C2, H1-C2) showed the greatest resistance to PO, and using the H-type screw as the following screw (C1-H2, H1-H2) showed superior resistance to rotational strength. However, the rotational strength of the C2 screw decreased by more than 50% compared with that of the original C screw. Moreover, the PO and rotational strengths of the H2 screw decreased to less than 30% overall compared with those of the original H screw. CONCLUSION The H-type screw should be used for second-time screw insertion procedures in cases where it is difficult to choose between PO and rotational strengths.
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Affiliation(s)
- Hong Man Cho
- Department of Orthopedic Surgery, Gwangju Veterans Hospital, 99 Cheomdanwolbong-ro, Gwangsan-gu, Gwangju, 62284, South Korea.
| | - Kwang Min Park
- Osong Medical Innovation Foundation, Medical Device Development Center, Cheongju, South Korea
| | - Tae Gon Jung
- Osong Medical Innovation Foundation, Medical Device Development Center, Cheongju, South Korea
| | - Ji Yeon Park
- Department of Orthopedic Surgery, Gwangju Veterans Hospital, 99 Cheomdanwolbong-ro, Gwangsan-gu, Gwangju, 62284, South Korea
| | - Young Lee
- Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul, South Korea
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16
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Sermon A, Hofmann-Fliri L, Zderic I, Agarwal Y, Scherrer S, Weber A, Altmann M, Knobe M, Windolf M, Gueorguiev B. Impact of Bone Cement Augmentation on the Fixation Strength of TFNA Blades and Screws. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:899. [PMID: 34577822 PMCID: PMC8465598 DOI: 10.3390/medicina57090899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Hip fractures constitute the most debilitating complication of osteoporosis with steadily increasing incidences in the aging population. Their intramedullary nailing can be challenging because of poor anchorage in the osteoporotic femoral head. Cement augmentation of Proximal Femoral Nail Antirotation (PFNA) blades demonstrated promising results by enhancing cut-out resistance in proximal femoral fractures. The aim of this study was to assess the impact of augmentation on the fixation strength of TFN-ADVANCEDTM Proximal Femoral Nailing System (TFNA) blades and screws within the femoral head and compare its effect when they are implanted in centre or anteroposterior off-centre position. Materials and Methods: Eight groups were formed out of 96 polyurethane low-density foam specimens simulating isolated femoral heads with poor bone quality. The specimens in each group were implanted with either non-augmented or cement-augmented TFNA blades or screws in centre or anteroposterior off-centre positions, 7 mm anterior or posterior. Mechanical testing was performed under progressively increasing cyclic loading until failure, in setup simulating an unstable pertrochanteric fracture with a lack of posteromedial support and load sharing at the fracture gap. Varus-valgus and head rotation angles were monitored. A varus collapse of 5° or 10° head rotation was defined as a clinically relevant failure. Results: Failure load (N) for specimens with augmented TFNA head elements (screw/blade centre: 3799 ± 326/3228 ± 478; screw/blade off-centre: 2680 ± 182/2591 ± 244) was significantly higher compared with respective non-augmented specimens (screw/blade centre: 1593 ± 120/1489 ± 41; screw/blade off-centre: 515 ± 73/1018 ± 48), p < 0.001. For both non-augmented and augmented specimens failure load in the centre position was significantly higher compared with the respective off-centre positions, regardless of the head element type, p < 0.001. Augmented off-centre TFNA head elements had significantly higher failure load compared with non-augmented centrally placed implants, p < 0.001. Conclusions: Cement augmentation clearly enhances the fixation stability of TFNA blades and screws. Non-augmented blades outperformed screws in the anteroposterior off-centre position. Positioning of TFNA blades in the femoral head is more forgiving than TFNA screws in terms of failure load.
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Affiliation(s)
- An Sermon
- Department of Traumatology, University Hospitals Gasthuisberg, 3000 Leuven, Belgium;
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | | | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland; (L.H.-F.); (I.Z.); (M.W.)
| | | | - Simon Scherrer
- DePuy Synthes Trauma, 4528 Zuchwil, Switzerland; (S.S.); (A.W.); (M.A.)
| | - André Weber
- DePuy Synthes Trauma, 4528 Zuchwil, Switzerland; (S.S.); (A.W.); (M.A.)
| | - Martin Altmann
- DePuy Synthes Trauma, 4528 Zuchwil, Switzerland; (S.S.); (A.W.); (M.A.)
| | - Matthias Knobe
- Department of Trauma Surgery, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland;
| | - Markus Windolf
- AO Research Institute Davos, 7270 Davos, Switzerland; (L.H.-F.); (I.Z.); (M.W.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland; (L.H.-F.); (I.Z.); (M.W.)
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